Healthcare Provider Details

I. General information

NPI: 1982839262
Provider Name (Legal Business Name): SUREVISION EYE CENTERS MIDWEST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2009
Last Update Date: 09/18/2023
Certification Date: 09/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 BROOKES DR STE 111
HAZELWOOD MO
63042-2735
US

IV. Provider business mailing address

320 BROOKES DR STE 111
HAZELWOOD MO
63042-2736
US

V. Phone/Fax

Practice location:
  • Phone: 314-726-5669
  • Fax: 314-726-5109
Mailing address:
  • Phone: 314-726-5669
  • Fax: 314-726-5109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: SHELLEY LYNN MIANA
Title or Position: COO
Credential: COE
Phone: 314-726-5669